Claims Team Leader

Description

     

Job Title: Claims Supervisor

Job Type: FT

Location: #LI- Remote, to be considered for this role, you must reside in one of the following states — AL, AK, AR, AZ, CT, DE, FL, GA, IA, ID, IN, KS, KY, LA, ME, MI, MT, MS, MO, NC, ND, NE, NH, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, WI, WV, WY     

 

Job Summary

We are passionate about our clients having a great experience and this also applies to our team and our future team members. Building a remarkable team is a top-level company priority. The Claims Supervisor is responsible for overseeing the day-to-day operations of the claims processing function, ensuring timely, accurate, and compliant adjudication of all participant claims. This role leads a team of Reimbursement Specialists and is accountable for production performance, quality standards, and turnaround times. In addition to internal team leadership, this role oversees and partners with outsourced claims processing vendor, ensuring alignment to service level agreements (SLAs), quality expectations, and operational standards. The Claims Supervisor plays a key role in driving operational performance through reporting, analytics, and continuous improvement, while maintaining strict adherence to IRS and regulatory requirements. This position reports to the Customer Service Manager.

What You’ll Do

  

Team Leadership & Development

• Lead, coach, and develop a team of Reimbursement Specialists, ensuring strong performance, accountability, and engagement.
• Conduct regular 1:1s, team meetings, and performance reviews aligned to production, quality, and compliance expectations.
• Support hiring, onboarding, and ongoing training to ensure team readiness and consistency in adjudication practices.
• Foster a culture of accountability, accuracy, and continuous improvement.

Claims Operations Oversight

• Oversee daily claims processing activities to ensure adherence to turnaround time (TAT) and productivity standards.
• Monitor workload distribution, backlog levels, and processing queues to maintain operational efficiency.
• Act as an escalation point for complex claims and adjudication decisions.
• Ensure consistent application of plan rules, documentation requirements, and IRS guidelines.

Vendor Management & Oversight

• Manage and oversee outsourced claims processing vendors, ensuring alignment with internal standards and contractual SLAs.
• Monitor vendor performance across quality, productivity, and turnaround time metrics.
• Partner with vendors to address performance gaps, provide feedback, and drive continuous improvement.
• Ensure clear communication, accountability, and operational consistency between internal and external teams.

Performance Management & Reporting

• Monitor and report on key metrics including claims TAT, accuracy, productivity, backlog, and quality scores.
• Develop and deliver daily, weekly, and monthly reporting to leadership, highlighting performance trends, risks, and opportunities.
• Utilize strong Excel and analytical skills to interpret data and drive informed decision-making.
• Identify trends and implement corrective actions to improve performance and reduce errors.

Quality Assurance & Compliance

• Ensure all claims are adjudicated in accordance with IRS regulations, plan documents, and internal policies.
• Conduct audits, identify trends, and provide targeted coaching.
• Reinforce documentation standards, substantiation requirements, and fraud awareness protocols.
• Maintain a high standard of accuracy and compliance across all processing activities.

Process Improvement & Operational Excellence

• Identify and implement process improvements to increase efficiency, reduce rework, and enhance quality.
• Partner with cross-functional teams to resolve systemic issues and improve workflows.
• Support transition initiatives, including process changes, system updates, and vendor integrations.
• Perform other duties as assigned.

Requirements

Who You Are  

• 3–5 years of experience in claims processing or reimbursement operations, preferably within benefits administration or healthcare.
• Prior experience in a supervisory or team lead role, with demonstrated ability to lead and develop teams.
• Strong understanding of claims adjudication, IRS regulations, and substantiation requirements.
• Experience working with or managing outsourced vendors or offshore teams.